Upon graduation, health care management students are expected to be confident, competent, reflective practitioners. We are also expected to provide data to support our assertion that we have accomplished this feat. Measurements of confidence can be obtained through student self-assessments. Assessments of competencies can be conducted via course work and face to face observations. What is a "reflective practitioner" and is this something we can objectively assess and document?
"Donald Schön called the phenomenon of learning through experience, “knowing-in-action” which becomes “knowledge-in-action” (Schon, 1982, p. 59)...What happens when the practitioner encounters something he/she has never seen before? Schon called it a “surprise” (Schon, 1987, p.26). The practitioner “reflects-in-action” during the first encounter, finds a “surprise”, goes and gets more information, then brings that information back to the problem. The practitioner then “reflects-on-action” afterward and adds to his/her knowledge base (Schon, 1987, p.26). When a wise practitioner coaches and mentors the trainee/student, he/she mirrors the trainee’s reflective process. The trainee, then, in turn, mirrors the wise practitioner’s process. Schon calls this the “hall of mirrors” (Schon, 1987, p.220)." (Buchbinder, Alt, Eskow, Forbes, Hester, Struck, Taylor, 2005, p. 261-262).
The above describes an ideal scenario, with a receptive student in a fieldwork experience being coached by a seasoned practitioner. However, in this era of rapid changes in healthcare organizations, it is rare to find an executive who has the time to walk the student through this process. Instead, I believe it is up to healthcare management educators to inculcate students with this approach beginning with their first class and continuing throughout the curriculum. As educators, we cannot rely exclusively on practitioners to do this for our students. We must drill this into them until it become an automatic reflex. The following are three examples of what I have used with students.
In online courses, Introductions tend to become repetitive and boring to students and the instructor, especially if you have had the students for a number of courses. In my Patient Satisfaction and Quality Improvement course, I pose the following question for the first week of the course.
Introductions: Please share the following about yourselves:
- The name you would like to be called by in this course;
- Your educational background;
- Your current job title;
- Where you would like to see yourself in 5 years; and
A personal experience/anecdote related to patient satisfaction (or dissatisfaction) and quality improvement in healthcare. It should begin with either “The worst thing that ever happened to me (or a family member)…” or “The best thing that ever happened to me (or a family member)…”
During the last week of the course, I have the students respond to this Discussion Question.
Closing the loop and moving forward...
Review your response to Discussion Forum 1 where you related "A personal experience/anecdote related to patient satisfaction or dissatisfaction and quality improvement in health care. It should begin with either “The worst thing that ever happened to me (or a family member)…” or “The best thing that ever happened to me (me or a family member)…"
Knowing what you now know from this course, reflect on that experience and respond to the following questions:
1. If your response was one of satisfaction, what did the organization do right to make you or your family member satisfied?
2. If your response was one of dissatisfaction, what should the organization have done to rectify the situation?
3. If you were the VP of CQI in a health care organization and a similar incident occurred on your watch, what would you do for service recovery?
4. In the future, when you or family members enter a health care organization to receive care, what are 3 indicators of quality you will be looking for in that encounter?
This approach has been well received by my students. They reflect on that incident and what they could have done differently. The "surprise," if you will, is the content they have learned through the course. This is also an example of requiring students to apply, integrate, and evaluate, all higher order thinking skills.
Case Studies and Role Play
In a previous blog, I wrote about the rehearsing for the real world with case studies and role play. After students complete a role playing exercise, it is important to have them sit down and reflect on the experience. It can be open-ended, or you can guide them with questions like the following ones:
- What competencies did you demonstrate in this role play?
- How did you feel during the role play?
- What, if anything, would you add to or change about this role play?
- What would you do differently if you were to have this experience in the real world?
Keep the students' responses as documentation of this reflective experience. My students have indicated this is a useful exercise that forces them to think about the role play, not just do it.
Journaling is a tool that not only requires the student to use writing and communication competencies, but also requires them to dig into their emotional response to either course materials or fieldwork experiences. They can be unstructured or structured.
At the graduate level, you may want to use an unstructured approach. Here is an example of one I use for a required course in legal and ethical issues.
Reflective Journal: Required, Not Graded
Legal and ethical issues in healthcare are both administrative and intensely personal. You are expected to journal throughout this course and to reflect on how the material is impacting you. Only you and I can see this journal. It will be useful for you in preparing later assignments where you will be graded on your reflections. My hope is this course will be a transformative experience for you and your personal and professional ethics.
The following are examples of structured reflective assignments for an undergraduate internship.
Oriented Anyone? Describe the first week of your internship. Was there a formal orientation? If yes, what did that include? If no, what was done instead? At this point in time, how do you feel about your decision to select this organization for your internship?
Skills of the Effective Administrator: In a previous course, you read an article by Katz about the skills of an effective administrator. He indicated that there were three skills—technical, conceptual, and interpersonal. Now that you are in your internship, please take a few moments to reflect upon what you now feel is the most important skill and why.
Balancing Acts and Health Care Managers: Part of being a good health care manager is that you learn about balance in your personal and work life. In your internship, thus far, have you seen good examples of health care managers performing this balancing act well? If yes, describe your observations. If no, describe why you believe their lives are out of balance.
Why Did You Choose Health Care Management? Why did you decide to major in Health Care Management? How that you are an intern, are you happy with that decision? What would you tell other students considering this major? Provide three (3) reasons why you think it’s a good major.
Motivation and Morale: Now that you’ve been in your internships for a while, what good examples of health care managers boosting morale have you seen? How much control do you think health care managers have over motivation and morale?
The Best of Times, The Worst of Times: What has been the best experience during your HCMN Internship? Conversely, what has been your worst experience? What have you learned from these experiences? Is there a take-away message you can share with others about these experiences?
Would You Do It All Over Again? Looking back over your HCMN Internship, would you do it the same way again? If you could rewind your internship, what might you have done differently? What advice can you offer to the next intern in this position about what they should expect and how they should prepare for it?
There are many reflective exercises available on the Internet from reliable sources, including Best Teachers Institute, Lipscomb University, and exercises for physicians. Your colleagues may have exercises they have used effectively and are willing to share. You could also elicit exercises from the students and have them vote on them to see which ones they want to use.
My question to you now is why wouldn’t you want to use reflective exercises?
Sharon Buchbinder is Professor and Program Coordinator for the MS in Healthcare Management at Stevenson University in the Graduate and Professional School and former chair of the Association of University Programs in Health Administration (AUPHA). She is also the author of three books from Jones and Bartlett: Introduction to Health Care Management (with Nancy H. Shanks), Career Opportunities in Health Care Management (with Jon Thompson) and Cases in Health Care Management (with Nancy H. Shanks and Dale Buchbinder.)
Here are some additional resources if you are interested in this topic.
Buchbinder, S.B., Alt, P.M, Eskow, K., Forbes, W., Hester, E., Struck, M., Taylor, D. (2005). Creating learning prisms with an interdisciplinary case study workshop. Innovative Higher Education, 29 (4): 257-274.
Kolb, D.A. (1984). Experiential Learning: Experience as the Source of Learning and Development. NJ: Prentice-Press.
Kreber, C. (2001). Learning experientially through case studies? A conceptual analysis. [Electronic version]. Teaching in Higher Education 6(2), 217-228.
Sasnett, B. S. & Ross, T. (2012, Spring). Does interprofessional education including reflection impact course performance? The Journal of Health Administration Education. 29 (2), 155-162.
Schon, D.A. (1983), The reflective practitioner: How professionals think in action. Basic Books.
Schon, D.A. (1987). Educating the reflective practitioner. San Francisco:Jossey-Bass Publishers.